Doctors seeing need for house calls as seniors age

GREENVILLE, S.C. — Homebound elderly patients who aren't ready for hospice care are benefiting from an old-fashioned concept that's regaining ground across the USA.

Dr. Romin Shah makes house calls, and Diana Fabiano, who has taken care of her frail, 85-year-old mother with dementia for the past 15 years, is extremely grateful.

"My goal is to keep her at home as long as possible, because at home she is taken care of better," Donnelly said. "It would be a hardship to try to get her back and forth. It's a two-man job to transfer her."

Shah arrives at Fabiano's home here carrying Rosemary Donnelly's chart and a backpack filled with his stethoscope, blood pressure cuff and other medical equipment.

He holds out a hand to Fabiano, then turns his attention to her mother.

The geriatrician was working as a hospice physician four years ago when he realized that some patients were being turned away because they weren't terminally ill. Hospice doctors make house calls. Yet the patients were so fragile and sick, they needed home care.

"There is a large population of frail, elderly, debilitated patients who are homebound," he said. "And if they don't get access to care, we will see them fall through the cracks, rehospitalized, going back to the ER."

Shah and his business partner, Johnnie Garmon, decided to fill the void by launching Providence Care, a medical practice that offers physician and nurse practitioner house calls to homebound patients.

Around the country, practices like these are beginning to sprout up as the population ages, said Alwyn Cassil, an independent health policy consultant with Policy Translation in Silver Spring, Md.

Government pilot project in 14 states

The Center for Medicare and Medicaid Services has a demonstration project in 14 states and the District of Columbia — though not South Carolina — to gauge the effectiveness and cost of providing care at home for up to 10,000 Medicare beneficiaries with chronic conditions.

"Home-based primary care allows health-care providers to spend more time with their patients, perform assessments in a patient's home environment and assume greater accountability for all aspects of the patient's care," CMS said in its description of the project.

The goal is to improve quality of care and quality of life. That's expected to keep patients out of hospitals and nursing homes for longer, which would lower health-care costs.

Elderly patients in their declining years consume the highest share of health-care spending, according to a Brookings Institution report, which notes the fastest-growing portion of the Medicare population is people with five or more chronic conditions.

While Medicare won't provide an estimate of savings, the Brookings report suggests that a 5% reduction in end-of-life costs would save Medicare $90 billion over a decade.

The number of Americans 65 and older is expected to grow from 40.2 million in 2010 to 54.8 million in 2020, according to the U.S. Census Bureau. And research shows they want to grow old in their own homes.

"Everybody wants to age in place, ... and most people can't afford a nursing home," said Magen Fowler, Providence Care's chief development officer. The average older patient sees five to seven doctors. "Families don't know what to do. We are trying to meet this huge wave of elderly people where they are."

Health care consultant Lynn Bailey of Columbia, S.C., called house calls "a desperately needed service."

Getting a homebound patient to the doctor often requires an ambulance, which costs $300 to $700 depending on the distance traveled, she said. And most physician's offices don't have a place to hold someone who's on a stretcher.

"It is very patient friendly to be able to have a nurse practitioner, physician assistant or physician come and see you in your home," she said. "It's a terribly needed service."

While 9 of 10 Providence Care patients are seniors, some patients are younger.

They may have dementia, like Fabiano's mother, Shah said. Or they have amyotrophic lateral sclerosis, better known as Lou Gehrig's disease; congestive heart failure; Parkinson's disease; chronic obstructive pulmonary disease; HIV; end-stage renal disease; or other conditions that leave them homebound.

Aging in place, her daughter's place

Shah listens to Donnelly's heart and takes a blood-pressure reading. He examines her skin for pressure sores and finding none, asks Fabiano whether her mother seems weaker than usual.

Donnelly was a vivacious auburn-haired stunner in her younger days, her daughter said.

She worked as a respiratory therapist at then Veterans Administration hospital in Cleveland before moving to her daughter's home in Buffalo, N.Y., after being diagnosed with dementia.

A sparkling conversationalist and avid reader, she loved spending time listening to her vast music collection. She was a gourmet cook who prepared beef Wellington and other memorable meals for her husband and four children.

"She was very pretty and nice, and she was always kind to people. She always looked for the good in somebody," her daughter said, smiling at her mother in a way that reveals she still sees her like that.

"This is a terrible disease," Fabiano said. "It really robs a person of their personality."

Now, Donnelly's gray hair is neatly pleated into a braid.

Each morning, Fabiano, a retired teacher who moved here last year to be closer to her daughters, rises and prepares her mother's medications, then gets her cleaned and dressed.

One of Fabiano's daughters helps get Donnelly into a wheelchair with a Hoyer lift — a device that uses hydraulic power to move people — and they roll her into the living room, where the lift is again used to transfer her to the recliner.

Fabiano fixes her mother's hair, gives her her breakfast and medications and turns on the TV or music.

"She's happy and comfortable there," she said. "It doesn't seem like she's actively watching, but I think she's listening."

After lunch, the routine is reversed so Donnelly can take a nap. Then she's brought back out for dinner and her evening meds.

Donnelly's life wasn't always like this.

In the beginning, she was just forgetful. She couldn't remember what happened the day before and kept asking the same question over and over.

But by 2000, Fabiano realized her mother couldn't live alone any more. So she turned her first-floor family room into a bedroom for her.

She's been unable to speak or move for several years now. She has trouble swallowing, making aspiration pneumonia a constant threat.

Her bones are so brittle that Fabiano always fears she'll cause a break just moving her from one room to the other.

Keeping up quality of life

Each day, Shah sees five to six patients. During his house calls, which can last up to an hour, he reviews lifestyle issues such as diet to make sure something like too much salt isn't aggravating a patient's condition.

He talks to the family about what to expect, such as worsening agitation with dementia. And he does a medical exam.

A major focus is on reviewing prescriptions for drug-drug interactions. Fowler said the average patient is on 10 to 15 medications. That can cause problems from altered mental states to falls, Shah said.

"We act as a safety net to help prevent this constant cycle of patients who need small tweaks in medications or adjustments in care to prevent them from going back to the hospital," he said. "A couple day's hospitalization will set them back weeks or months."

After looking over Donnelly's medications, Shah takes her off an Alzheimer's drug, which he says has been shown only to be of modest benefit in the first six months of dementia.

Like most patients with chronic illnesses, Donnelly is seen every five to eight weeks, more often if they're having problems, Fowler said.

Providence also partners with a company that provides home laboratory and X-ray services and with home health, therapy and social work services so patients don't have to leave for those supports either.

Growing business

With three offices in South Carolina, Providence Care, which has a sister company that offers hospice services, now has 1,500 and 2,500 patients statewide, Fowler said.

Often, patients are referred by other doctors because they've missed appointments with them, she said.

While Shah was the only one making house calls at first, the business soon grew so much that three nurse practitioners and another physician were added to the mix.

It's hard to recruit doctors who want to work in the home, Fowler said, but she's trying.

Medicare and Medicaid cover house calls and reimburse them at the same rate as a doctor visit, or about $125 to $175, according to Providence. The company also has a nonprofit foundation funded by donations that cover uninsured patients, she said.

Though caring for her mother is sometimes a challenge, Fabiano says she doesn't mind. She wants her to have the best life she can.

"She's aware on levels that people don't realize," she said. "When she's in an unusual situation, she's frightened. She'd rather be here at home."

Patients with dementia commonly get upset when they are taken out of their routines, Shah said. And that can lead to a vicious cycle of worsening symptoms, more medications and sometimes delirium.

"The most effective thing for her and her quality of life is to be home with her loved ones," he said. "We need to respect those wishes."